Many of you are no doubt aware of the study released last week by the Birthplace in England Collaborative Group. The purpose of the study was to take a detailed look at the risks associated with different settings where women with low-risk pregnancies plan to give birth: hospital OB units, midwifery-run birth centers within or close to hospitals, freestanding birth centers, and at home.

The study ran from April 2008 to April 2010. The measured outcome was a composite of things that can go wrong for babies at birth: death at or just after birth, and injuries that may occur during birth such as broken bones, traumatic nerve injury, brain injury and a type of respiratory distress called meconium aspiration syndrome .

The findings: overall, birth for low-risk women was equally safe in all four settings. In other words, low-risk births anywhere in England tended to have low rates of bad outcomes.

When the data was carved up a bit more, one difference popped up: women having their first babies at home were 2 to 3 times more likely to have bad outcomes than those giving birth in any of the other settings. The risks were still quite low, but the increase was statistically significant.

The British press jumped all over that statistic. Many were quick to condemn all home birth as dangerous and not all the reporting was accurate. (See the Daily Mail story here, which exaggerates the risk of death or brain damage.)

Cooler heads are still trying to have themselves heard over the tabloid din. Britain’s National Health Service, which directs midwifery care in England, has an excellent review of the study’s findings and the risks of home birth (which includes the definition of a low-risk pregnancy, too). It’s well worth the read.

What seems to have been somewhat overlooked in all hubbub about risks to first-time mothers is what the study found about women having second or later babies. There was no safety difference for these mothers in any of the birth settings – birth at home was as safe as anywhere else. Fortunately, some reporters picked up on that part of the story.

So what’s the Birthplace in England study’s bottom line? That low-risk births generally go well, regardless of where they happen. A first-time mother planning a home birth needs to be aware of the small but significantly increased risk her choice entails, and second-time moms should be fine regardless of birth setting.

Ah, but that’s in England, where home birth is integrated into the larger maternity care system. The U.S. is a whole different story. And there’s more to assessing risk of place of birth than focusing on immediate outcomes. More on that soon.

2 responses to “Making sense of ‘Birthplace in England’”

I have an at-home midwife and an OB who have an existing professional relationship. In the U.S. In the Bay Area in California, specifically. Having had a very smooth first delivery, at my first prenatal check-up with my OB in my second pregnancy, I mentioned considering a home birth. He recommended an at-home midwife that he’s worked with before. However, due to an unusual health concern, the OB wanted me to have monthly ultrasounds to check the growth of the baby. So I’ll be seeing my at-home midwife every 3 weeks, and my OB every 4-6 weeks. This sounds, to me, akin to the “integrated” model of health care that the U.S. doesn’t have. What are your thoughts?

Hi Ania,
I’m sorry to be so late in replying – I’ve been offline the last few days.
The relationship you describe between your midwife and your OB is certainly a step in the right direction toward integrated maternity care. Unfortunately such relationships are fairly rare in the U.S., and the lack of a close OB-midwife working relationship is the source of many of the problems associated with U.S. home birth. Critical to a midwife-friendly, integrated maternity care system is smooth, seamless emergency care–getting a woman to the specialty care she needs quickly when things are going wrong.

In many British Columbia hospitals women laboring at home are routinely added to the hospital’s labor and delivery “board” at the onset of labor, right along with the names of the women physically present in the unit. If the birth goes smoothly, the midwife calls in when the baby is born and the woman’s name is removed from the board. If there is a complication necessitating transfer, that woman is then already a “known” patient, and her arrival is planned for. The woman’s midwife can accompany her to the hospital and take part in her care there. That’s a far cry from what usually goes on in the U.S.

You’ve probably already done this, but particularly because you mention having a health concern with this pregnancy, be sure that your midwife has a very clear plan as to what will happen if there are complications. And depending on the health concern you’re having, you might want to re-think the plan to give birth at home. The statistics showing home birth to be as safe as hospital birth are for selected, uncomplicated pregnancies. Safety risks increase with more complicated pregnancies.

Good luck with baby #2! I hope everything goes well for you.
Take care,
Mark